Summary On 31 October 2000, the MV Mokami was transiting the narrow waters of the Labrador coast with a partial load of refined products to be discharged at Voisey's Bay, Labrador. Upon approaching Bridges Passage, the officer of the watch ordered a course alteration to follow the recommended route on the Canadian Hydrographic Service chart No5052. As the vessel was swinging to starboard to steer a course of 134gyro, the Mokami ran aground on the shoal east of buoy NP5 at 1544 local time, causing extensive damage to the hull. The Mokami was refloated after transferring some cargo to the Sybil W. The grounding caused minor pollution in the vicinity which later dissipated. There was no injury. Ce rapport est galement disponible en franais. Other Factual Information Particulars of Vessel Description of the Vessel The Mokami is a small coastal tanker carrying refined petroleum products to different locations on the Labrador coast. The vessel has four centre tanks and four wings tanks for cargo and nine ballast tanks including a forepeak ballast tank. History of the Voyage On the evening of 27October2000, the vessel left Holyrood, Newfoundland, for Nain, Labrador, with 1926 cubic metres of refined petroleum product. The vessel was loaded to her marks and her draught was 4.2m forward and 5.6m aft. The vessel discharged a partial load of cargo at Nain and Ten Mile Bay. She then departed for Voisey's Bay at 13001 on 31October to complete cargo discharge. The distance between Ten Mile Bay and Voisey's Bay was estimated at 60miles. The chart in use was Canadian Hydrographic Service (CHS) Chart No5052 with North American Datum 1983 (NAD 83) chart datum. When the vessel was north of the Bridges Passage, the officer of the watch (OOW) took over the con of the vessel and the master was calling Eastern Canada Traffic System (ECAREG). The master completed the ECAREG message when the vessel was off Stony Point. The weather was fine and clear with light winds. The current was setting to the NE at approximately 3-4knots(kt). When off Palungitak Island, the vessel's course was altered to 096 as per the recommended track. The bridge was crewed by the OOW in charge of the piloting, with the master assisting and the second officer at the helm. The third officer and the cook were standing by but were not involved in the navigation of the vessel. The master was checking the global positioning system (GPS) coordinates and was using visual markings ahead. A couple of minutes prior to the grounding, the master used the GPS to verify the vessel's position but did not plot it on the chart. According to this observation, the vessel was mid-channel. The OOW was using parallel indexing as a method of navigation and was referring to the chart at times. The vessel's position was not plotted on the chart. The vessel was proceeding at 70percent of her engine speed which, combined with the current, gave the vessel an estimated speed of 10kt. With the buoy NP5 abeam 130m distant and Rain Islet at 5.5cables, the OOW ordered course alteration in increments to 105, 110, 120 before steadying on a course of 134 as per the recommended track. At about this time, the vessel ran aground at 1549, approximately 200m NE of buoy NP5 (see Figure 2). The vessel sustained severe damage to the hull structure. The cargo tanks were holed, causing minor pollution. Events Following Grounding The master ordered sounding of the tanks and reported the occurrence to Transport Canada Marine Safety (TCMS) St. John's. The Oil Pollution Response Team was notified and divers from St. John's were requisitioned to survey the hull. As the tanker Sybil W was in the area, she was requested to come alongside the Mokami to unload a partial cargo. Meanwhile, a boom was deployed to contain the spill but it became submerged due to the current. Following underwater inspection and evaluation of the damage, TCMS gave permission to the vessel to proceed to Halifax, Nova Scotia, for repairs. The vessel proceeded at slow speed and arrived at Halifax on the morning of 7November. Navigation Equipment The navigation equipment included a GPS which was interfaced with the starboard radar/ARPA (Automatic Radar Plotting Aid) and was used by the OOW. No way point was input for Bridges Passage. The gyro error was 0.5high. The course recorder was not recording as the crew was not familiar with its use and the instructions and the functions for its operation were in Russian. Further, all of the labels on the bridge, as well as some of the navigational instruments including the navigation console, were in Russian and their manuals had not been translated. Notwithstanding the above, at the time of the occurrence, labels and manuals for the main instruments in use for navigation were in English. Vessel and Personnel Certification The vessel was crewed, equipped, and operated in accordance with existing regulations for a vessel of her size and trade. Vessel Manoeuvrability in Bridges Passage The Canadian Coast Guard (CCG) has developed a document, titled Canadian Waterways National Manoeuvring Guidelines: Channel Design Parameters, which provides planners with a set of criteria to be used when determining waterway parameters required to provide sufficient manoeuvrability with no less than minimum safety margins and allowances. The Mokami met the criteria for safe transit through Bridges Passage. Bridge Resource Management The essence of bridge resource management (BRM) is the effective use of all available resources to complete an operation safely. BRM addresses managing attention, operational tasks, stress, attitudes, and risks. BRM recognizes that individual, organizational, and regulatory factors are involved in safe and effective operations. Optimizing the management of these elements has a direct effect on four factors critical to the successful outcome of any operation: situational awareness : recognizing and defining the nature of the problem encountered; metacognition : reflecting on and regulating one's own judgements or decisions; shared mental models : involving others in the problem-solving process; and resource management : understanding tasks to be performed, their priorities, and required and available resources. Successful BRM programs address several key areas, such as team building and maintenance, communication and decision-making processes, workload management, situational awareness, watch systems, and working environments. Team Building and Maintenance Individual characteristics of team members are important. However, in a team, work is shared, tasks are performed in a more timely and effective manner, and a higher level of performance is achieved than that by an individual working alone. Research has demonstrated that, during the team formation process, patterns of communication and interaction are established.2 Once established, the process continues and leads to activities that can maintain patterns of effective (or ineffective) group communication. Communication and Crew Decision Making Processes Crew decision making is managed decision making. In this instance, the OOW was responsible for making the decisions but was supported by input from the crew, both on the bridge and from shore (e.g., traffic services). This requires a group climate that encourages participation and the exchange of information. Poor communication can result in crews not sharing a common understanding of a situation, or in a misunderstanding of the OOW's intentions. Workload Management The essential tasks for safe navigation of the vessel are allocated to different persons best equipped or experienced to perform them so that no member of the bridge team carries a workload that is beyond his/her capabilities. Situational Awareness Situational awareness is the accurate perception of factors and conditions that affect a vessel and its crew during a defined period of time.3 More simply stated, it is knowing what is going on around you. The safety of the voyage depends on the level of situational awareness of the individual who has the conduct of the vessel. The ease and effectiveness of communication is a fundamental factor in maintaining optimal situational awareness. It is essential that each member of the bridge team does everything feasible to support the person in charge to maximize his level of situational awareness. No one had received training on BRM and techniques were not applied by bridge personnel to ensure safe transit. Communication between bridge personnel during the transit was minimal. Navigation was carried out in isolation with minimal input from the master. No passage plan had been discussed and/or prepared for the transit. Safety Management System Convention tankers are required to comply with the International Safety Management Code, whereas non-convention tankers such as the Mokami, which ply locally, are not required to have any form of a safety management system. A review of the Mokami's operations indicated, among others, the following: the company's shore-personnel provided minimal guidance to the crew on the operation of the vessel; the selection criteria for the crew was limited to the Transport Canada (TC) mandatory certification requirement; no person was assigned to identify the training needs of the crew; additional training, such as BRM, was left to the discretion of the crew and the company policy with respect to training lacked specifics; none of the crew had BRM training; neither the master nor the crew had received training on the use of GPS and were not aware of the need to set the selector switch to the corresponding chart datum; and safety bulletins issued by the company were sparse and TC Ship Safety Bulletins (SSBs) were not dispatched to the vessel. Status of Hydrographic Charts The CHS has the mandate of charting Canadian waters for the benefit of all mariners. Their task is to provide a reliable scientific basis to enhance the safety and efficiency of navigation for vessels operating in Canadian waters. A review of the chart for the area revealed the following: CHS chart No4748 had been replaced with the new chart No5052 on 25April1997. The scale of CHS chart No4748 was 1:80000 and contained an inset of Bridges Passage on the scale 1:25000. The chart was geographically referenced to an astronomic observation spot on Stony Islet; thus the chart is referenced to an orphan or unknown horizontal datum. The scale on chart No5052 had been increased to 1:60000 but the inset of Bridges Passage had been removed. The chart datum used was NAD83. Horizontal Chart Datum and Safety Many different definitions of a horizontal datum, also known as geodetic datum, exist. However, a practical working definition in use is: A horizontal datum is a reference system for specifying positions on the Earth's surface. Each datum is associated with a particular reference spheroid that can be different in size, orientation and relative position from the spheroids associated with other horizontal datums. Positions referred to different datums can differ by several hundred metres.4 Charts use different horizontal chart datums as a reference for specific geographical positions. The process of converting all charts to World Geodetic System 1984 (WGS-84) datum is in hand, however, a large number of charts have not yet been converted. This means that positions obtained from satellite navigation receivers are not compatible with the chart and an adjustment is warranted for position accuracy. The latitude and longitude from a navigation receiver such as a GPS are referenced to a specific horizontal datum which may be at variance with the horizontal chart datum. Consequently, unless the GPS receiver datum is the same as the chart datum, the receiver datum must be converted to the chart datum for position accuracy. GPS makes direct use of WGS-84, which is equivalent to NAD83 now used by the CHS. Most GPS receivers incorporate datum transformations into their software. This allows a mariner to select the appropriate datum that is compatible with the chart. Furthermore, the most accurate position is obtained by having the GPS receiver referenced to WGS-84 (NAD83) and the application of the datum adjustment published on the chart. Familiarity with the use of the datum selection feature on the GPS receiver is essential for accurate position fixing. In this instance, the bridge personnel had little knowledge of the chart datum and the need to set the selector switch to the corresponding chart datum in use. The GPS was set to NAD 27 while the chart in use (No5052) was referenced to datum WGS-84 (NAD83). The impact of chart datum on navigation safety has been recognized by the International Maritime Organization (IMO) as well as CCG. The IMO publication SN/Cir.213, dated May2000, entitled Guidance on Chart Datums and the Accuracy of Positions on Charts, and the CCG publication, entitled GPS/DGPS Made Easy, edition 2000, provide instructions on how a datum shift can be applied to a chart. Much of the Labrador coastal waters have not been surveyed to modern standards.5 The CHS recognizes that with the advent of GPS and electronic chart systems for navigation purposes, it has become necessary to facilitate the use of a geographic co-ordinates system, WGS84 or NAD83. CHS has initiated action to bring the charts to the NAD83 datum and is surveying corridors along shipping routes to modern standards. Meanwhile, many off-datum charts with unknown older horizontal datums still exist for the Labrador coast. As such, they cannot be geographically referenced to any satellite-based system. The caution contained in the Annual Edition of Notices to Mariners (Notice2.7) reminds mariners that, due to differences in horizontal datum (i.e., NAD27, NAD83), grids of charts of an area may vary from one chart to another. Use of Global Positioning Systems and Safety GPS positioning does not offer integrity monitoring similar to that which is provided with a differential global positioning system (DGPS). Further, the U.S. government does not provide continuous real-time monitoring of the system's performance. Satellites can automatically remove themselves from service when they experience any of a number of specified failure modes.6 However, when a service failure occurs that is not covered by the automatic removal capability, the failure must first be detected when the satellite is above the horizon of the monitoring station antenna before the U.S. Department of Defence (DoD) can respond by manually removing the satellite from service. Meanwhile, unhealthy signals from a malfunctioning satellite may continue to be used by receivers until taken out of service. Further, ionosphere, troposphere, receiver, multi-path, and interference can affect the accuracy of GPS positions. Consequently, caution must be exercised when GPS is used for position fixing purposes. Responsibility of the Canadian Coast Guard for Marine Aids CCG is responsible for providing and maintaining fixed and floating marine aids to navigation in Canadian waters. Regular and effective checking of these aids to ensure their proper position, operation, and characteristics is considered an important part of this responsibility. All relevant aspects of CCG aids service-checking activities, including checking schedules, acceptable checking methods and record keeping, are outlined in the Marine Aids Administrative Directive 2.2400 -- Aids Checking Standard. In the case of floating aids, buoy data is maintained in one of two systems, the manual Buoy Data Cardex System or the Systme d'information de positionnement des aides (SIPA), an electronic database. Pertinent details of the checking and servicing performed on buoys are recorded on a field document known as the Buoy Service Report (BSR). The investigation revealed a number of discrepancies in the data cards for buoys observed by buoy tender personnel. The discrepancies were brought to the attention of the CCG Marine Navigation Services (MNS) superintendent in June 1998. The following year, it was observed that the buoy data cards issued to the ships had not yet been corrected. Concerned about the continued discrepancies, questions were raised whether ships should continue sending this information to CCG or forward this information directly to other vessels. History of Buoy NP5 Figure2. CHS Vector Chart NoCA 409425 (Courtesy NDI)